Friday, October 7, 2016

One thing I’ve
learned is that physicians who have gone into direct primary care (DPC)
practices are passionate about their decision: they not only believe that DPC
is better for their patients and their own professional and career
satisfaction; many assert it is the
answer to just about everything ailing primary care. There is an evangelical fervor among some DPC advocates to spread the word and convert
other primary care physicians to their cause.

It’s no surprise to me, then, that many of them have expressed
frustration—to put it mildly—that ACP has decided not to endorse or promote
DPCs. Instead, our
2015 position paper, for which I was the lead author on behalf of the
College’s Medical Practice and Quality Committee, aims to provide a balanced
and evidence-based assessment of the potential impact on patients of practices
that have one or more of the following 3 features:

They charge monthly per patient retainer or subscription fees.

They do not participate in insurance contracts.

They have reduced their patient panel sizes well below the
norm.

The American
Academy of Family Physicians says that “Generally, DPC physicians have a
panel of between 600 and 800 patients. In typical FFS settings, the patient
panels tend to range from between 2,000 and 2,500 per family physician.”

One of the challenges ACP found in assessing the impact of
direct primary care is that it is only one variation of practices that charge retainer
fees, do not participate in insurance, and/or have smaller patient panels. For example, practices often described as
“concierge” practices often charge much higher monthly per patient retainer
fees than most DPCs say they charge. (Many
DPC proponents fiercely object to being labeled as concierge practices).

Yet ACP found little in the literature that defines the
accepted range of monthly fees charged by DPC compared to “concierge” practices—Medical
Economics magazine says they typically range from $50 t0 $150 per month, citing
AAFP. A study in the Journal of the Board of Family
Medicine (JBFM), which was published after ACP had completed the literature search
for our paper, reported that
“Practices that used the phrase DPC on average charged a lower fee than
practices that used the term concierge to describe their model: $77.38 compared
with $182.76, respectively. Of 116 practices with available price information,
28 (24%) charged a per-visit fee, and the average per visit charge among this
group was $15.59 (range, $5 to $35). Thirty-six of these 116 practices charged
a one-time initial enrollment fee, and the average enrollment fee among this
group was $78.39 (range, $29 to $300).”

The wide variations in the monthly fees charged begs the
question: at what point, does the
monthly fees charged by DPC practices make them concierge?

Our paper found examples of DPCs that provide low cost and
accessible services to all types of patients, including Medicaid patients. Yet we also observed that there is a
potential that less well-off patients, who can’t afford to go without insurance
or pay a monthly fee, might be disadvantaged.
Guided by our Committee on Ethics and Professionalism, we accordingly urged
physicians who are considering DPC, concierge or other practice arrangements
that have one or more of the features described above to consider steps, like
waiving or lowering monthly fees for patients who can’t afford them, to
mitigate any potential impact on undeserved patients. Perhaps most importantly, we called for more
research on the potential impacts of such models.

This reasoned position, neither endorsing nor opposing
DPCs, instead calling for more research
and consideration by physicians who enter into such practices of steps that
could mitigate any adverse impact on poorer patients, has been misinterpreted
by some DPC advocates as ACP being opposed to DPCs. This
is not the case. Our paper clearly
states that physicians should have a choice of entering into practice arrangements
that provide ethical and accessible care to their patients, which can include
DPCs that meet the ethical considerations laid out in paper.

In a recent letter published
in the Annals of Internal Medicine, I responded to a letter from Dr.
Martin Donahoe that was highly critical of what he called “luxury care
clinics,” especially in academic medicine. I cautioned against painting too broad a brush
in characterizing the motivations of physicians who charge monthly retainer
fees and have downsized their patient panels:

“I have met many
physicians who have gone into concierge and direct primary care practices
precisely because they want to get back to doing what they love most, which is
spending time with patients. Many say
that they charge low monthly fees so that they can be accessible to moderate-
and low-income patients at less out-of-pocket cost to patients than many
high-deductible insurance plans offer. I caution against painting with too
broad a stroke in assessing the motivations of physicians in practices that charge
retainer fees or limit the numbers of patients they see and about the effect
that such features have on poorer patients. Rather, we need more unbiased
research and evidence—while strongly reminding physicians, as we do in our paper, of
their ethical obligations to provide care that is nondiscriminatory based on a
patient's income, gender and gender identity, sexual orientation, race, or ethnicity,
regardless of the type of practice—concierge or not.”

I am heartened that Dr. Bob Centor, chair-emeriti of the ACP
Board of Regents and a long-standing proponent
of direct primary care, blogged
that my Annals letter was “a very thoughtful rebuttal” to Dr. Donahoe’s
broad condemnation, noting that “ACP has an excellent position paper on direct
primary care,” referring to our 2015 paper.

Yet some DPC evangelists remain unsatisfied with the College’s
position that we need more research on the impact of DPCs on quality, access and cost, especially for
underserved populations. One DPC
evangelist—a DPC physician himself, and one of the co-authors of the AJFM study
cited above—called
the analysis by ACP, our Medical Practice and Quality Committee and our Ethics,
Professionalism and Human Rights Committee “ignorant”—even though his own ABFM study concluded
that “Most DPC practices are young and small and thus lack sufficient quality
and cost data to assess outcomes thus lack sufficient quality and cost data to
assess outcomes.” Calling one’s
colleagues in another primary care field “ignorant” is a sure fire way to win
people over!

Finally, it needs to be acknowledged that there is a
significant crossover between DPC advocates and anti-Obamacare physicians. Just do a Google search of “direct primary
care as an alternative to Obamacare” and you’ll find dozens of commentary about
why DPC is a “free market” alternative to the Affordable Care Act’s insurance
regulations, alternative payment models, and other features. ACP, which strongly supports the ACA’s
benefit requirements, subsidies, and consumer protections, would have
difficulty embracing a movement that many of its own advocates assert is
intentionally designed to subvert the ACA.
DPC, on the other hand, could be a reasonable option that exists as
already permitted by the ACA, as long as it doesn’t weaken the law’s consumer
protections.

So this is how I see things.
It is fine for DPC advocates to promote the benefits of this model. It is fine that many physicians are
considering going into a DPC, motivated by their desire to desire to spend more time with their patients,
although I would encourage them to consider the steps recommended in our paper
to mitigate any adverse impact on poorer patients. It is fine—in fact, imperative—that there be
more research on the impact of DPCs on quality, cost, and access. However, the evangelical strain of the DCP
movement that seeks to convert ACP, and everyone else, to endorsing the
movement—you're either for or against them—is not going to result in the
respectful, evidence-based dialogue that is needed.